An original technical certification system and rules were established for introducing novel endoscopic procedures at our hospital. In this study, we evaluated the safety and feasibility of introducing 8 novel endoscopic procedures. Of the 8, 6 procedures could be safely introduced, except esophageal and liver resections. In these two procedures, we were necessary for 3 laparotomies and 2 reoperations. Therefore, we must be careful while selecting the indications and patients for these procedures.

Objection: The elderly population, which carries an increased risk of postoperative complications, is increasing in size. “Frailty” is a new concept for assessing the surgical risk in elderly patients. We analyzed the usefulness of assessing frailty for predicting postoperative complications in patients ≥60 years of age undergoing colorectal cancer surgery.

Methods: We conducted this prospective evaluation in 65 colorectal cancer patients ≥60 years of age who were underwent surgery for colorectal cancer. As relatively simple tools to predict the risk of postoperative complications, we evaluated the performance status, Barthel index, American Society of Anesthesiologists physical status, prognostic nutritional index and frailty. We also recorded the incidence of Grade ≥Ⅱ postoperative complications according to the Clavien-Dindo Classification.

Results: A bivariate analysis showed that frailty was significantly associated with the risk of postoperative complications (p = 0.049). A multivariate analysis also identified frailty as being significantly associated with the risk of postoperative complications (p < 0.030).

Conclusion: Assessment of frailty may be a useful tool for predicting the risk of postoperative complications in patients aged ≥60 years old.

Aim: A linear stapler, loop-ligature device, or clipping device is commonly used for closing the appendiceal stump after laparoscopic appendectomy (LA). It is also possible to ligate the appendiceal stump directly and extracorporeally at the umbilical incisional site in single-port LA. In this study, we investigated the success rate and efficacy of direct ligation and the risk factors that would preclude adoption of this method for appendiceal stump closure.

Methods: A total of 136 patients who underwent LA for acute appendicitis between January 2017 and December 2019 were included in this study. The patients were divided into two groups (the direct closure group and indirect closure group), and the postoperative outcomes and cost of closure were compared between the two groups. Multivariate analysis and ROC analysis were performed to identify the risk factors that would preclude adoption of the method of direct ligation at the umbilicus.

Results: The success rate of direct ligation was 80.9%. Direct ligation was also less expensive than the device-assisted methods. Univariate analysis identified age, BMI, three-dimensional distance (from the umbilicus to the appendix), thickness of subcutaneous fat, and presence/absence of an abscess as high-risk factors for adoption of the direct ligation method. Multivariate analysis after adjustments identified only age and BMI as significant factors; the cutoff values for age and BMI were 24.5 years and 21.5 kg/m², respectively.

Conclusion: Transumbilical extracorporeal stump closure can be performed with a high probability of success, and is safe and inexpensive. However, it may prove difficult in older patients and patients with a relatively high BMI, and appropriate caution is needed in such cases.

Myotonic dystrophy type 1 (DM1) is a hereditary autosomal dominant muscle disease characterized by myotonia. It is known to be associated with various complications such as cardiac arrhythmias, abnormal glucose tolerance, and benign or malignant tumors. Herein, we report a case of a huge phyllodes tumor of the left breast in a patient with myotonic dystrophy type 1. The patient was a 39-year-old woman suffering from idiopathic chronic respiratory failure. Examination revealed a tumor in the left breast and the patient was referred to our hospital. She was diagnosed as having DM1 based on genetic analysis, and a phyllodes tumor in the left breast. We planned surgery for the tumor, however, we withheld the surgery, as the patient had severe respiratory failure. DM1 is reported to be associated with a high incidence of benign or malignant tumors. Attention should be paid to the occurrence of tumors in these patients; screening should be performed for tumors and prompt treatment should be provided before the general condition of the patient becomes worse.

We report the use of indocyanine green (ICG) fluorescence imaging for intraoperative navigation in a case with interpectoral lymph node recurrence of breast cancer.

A 63-year-old woman. At the age of 57, she had undergone mastectomy with axillary lymph node dissection for left breast cancer. At the age of 62, ultrasonography revealed an interpectoral lymph node measuring 11 mm in a diameter, and fine-needle aspiration cytology of the node revealed adenocarcinoma; suspecting metastatic carcinoma, axillary lymph node dissection was performed. The interpectoral lymph node was confirmed by ICG fluorescence imaging, and the lymph node was excised together with the pectoralis minor muscles.

In the case of reoperation, it may be difficult to identify a lymph node in the scar tissue, and ICG fluorescence imaging may be useful for identifying lymph nodes. In addition, the method may be useful to ensure that no lymph nodes are left behind.

A 78-year-old-man referred to our hospital with right chest pain was diagnosed based on the clinical findings and CT as having spontaneous rupture of the mid-esophagus. He was receiving regular treatment with a steroid for bullous pemphigoid and an antiplatelet drug(s) for arteriosclerosis obliterans, and was under maintenance hemodialysis initiated for end-stage renal disease caused by diabetic nephropathy. Emergency operation for the ruptured esophagus was started 9 hours after the onset of his symptom. Irrigation and drainage of the thoracic cavity, suturing of the perforated esophagus, coverage of the defect with an intercostal muscle flap, and tube-jejunostomy were performed. On day 10 after the surgery, sutural leakage was diagnosed from the purulent discharge and findings of CT, and reoperation was performed. Irrigation and drainage of the thoracic cavity was performed. In addition to the two thoracic drains, a trans-hiatal mediastinal drain was also inserted from the abdomen. Although an esophago-thoracic fistula had formed and prolonged conservative treatment was required, the fistula eventually closed, aided by insertion of the trans-hiatal mediastinal drain. All drains were removed on day 92 after the surgery and the patient was discharged from the hospital on day 120 after the surgery. The leakage after the surgery could have occurred on account of several risk factors in the patient, including the advanced age, site of rupture in the esophagus, and underlying diseases, and trans-hiatal drainage was effective for closing the leakage.

We present the case of a woman in her 80s who had been diagnosed as having a submucosal tumor protruding within the intragastric cavity, associated with an esophageal hiatal hernia a year earlier. As there were no symptoms, she was treated by a conservative approach, with regular follow-ups. The patient was referred to us when she developed anemia. Thoracoabdominal computed tomography revealed herniation of the fornix and antral zone of the stomach into the mediastinum. In addition, a low-density mass measuring 4 cm in diameter was found protruding into the intragastric cavity. Upper gastrointestinal endoscopy and an upper gastrointestinal series revealed a mixed-type sliding esophageal hiatal hernia, as well as a submucosal tumor in the gastric body. There was an ulcer at the tumor apex. The cause of anemia was determined to be hemorrhage from the tumor, and we performed radial excision of the esophageal hiatal hernia and laparoscopic partial gastrectomy. Histopathology of the resected specimen revealed a tumor measuring 4 cm in diameter, that was composed of proliferating spindle-shaped neoplastic cells; mitotic figures were present and immunohistochemistry revealed positive staining for KIT and CD34. Based on the findings, the tumor was diagnosed as a very low-risk gastrointestinal stromal tumor. We discuss the laparoscopic radical surgery performed for the patient, together with a brief review of the literature.

We report a case of laparoscopic-assisted surgery for intussusception caused by Peutz-Jeghers-type polyps. An 18-year-old woman was referred to our hospital because of abdominal pain and vomiting. A contrast-enhanced computed tomography examination showed a small intestinal intussusception caused by large polyps in the ileal tract. We performed an emergency laparoscopic-assisted surgery with partial resection of the ileum. The intraoperative findings revealed an intussusception about 30 cm length in the oral intestine at a location 160 cm from the terminal ileum. The histopathological diagnosis was hamartomatous polyps in a patient with Peutz-Jeghers syndrome. We herein report this case in detail and review the relevant literature.

A 70-year-old woman was admitted to our hospital with abdominal pain, vomiting and diarrhea. Abdominal computed tomography (CT) showed volvulus of the small intestine and gas accumulation in the intestinal wall, and urgent surgery was performed. Intraoperative examination revealed torsion of the small intestine and numerous gas-filled cysts in the small intestinal wall, but no ischemic changes or perforation of the intestine. Thus, repositioning of the small intestine was performed without bowel resection. After the surgery, the patient was diagnosed as having systemic sclerosis based on the presence of skin sclerosis on the fingers and seropositivity for anti-centromere antibody. The patient was initiated on appropriate treatment and both the systemic sclerosis and abdominal condition remain well-controlled under medication. Herein, we report a case of systemic sclerosis diagnosed after surgery for pneumatosis cystoides intestinalis with volvulus of the small intestine, with a review of the literature.

We report the case of a patient with rectal neuroendocrine carcinoma who presented to our hospital with hemorrhagic shock and was treated by elective laparoscopic surgery. We report the case along with a review of the literature. A 71-year-old man was admitted to our hospital with hemorrhagic shock. Emergency endoscopy was performed, and we found a type 2 rectal tumor measuring 20 mm in diameter as the source of active bleeding. We performed endoscopic hemostasis, followed by laparoscopic high anterior resection with D2 lymph node dissection. Although the resected specimen revealed rectal neuroendocrine carcinoma (T2N2aM0, pStageⅢB), we did not initiate adjuvant chemotherapy, in view of the patient’s background. Nine months after the surgery, multiple lung metastases and left internal iliac lymph node metastasis were detected and the patient was managed by palliative home care.

A woman in her 30s diagnosed as having advanced lower rectal cancer was treated by neoadjuvant chemoradiotherapy (S-1 80 mg/m², RT 40 Gy/20 fr), followed by laparoscopic low anterior resection with right lateral lymph node dissection and construction of a loop ileostomy. One month after the surgery, abdominal CT showed a 6×4 cm lymphocele formed in the pelvic cavity on the right side, not associated with any symptoms. The lymphocele showed little increase in size over the following 6 months. However, by this time, the patient began to complain of paresthesia in the right thigh. Therefore, 8 months after the surgery, ileostomy closure and laparoscopic fenestration of the lymphocele were performed, after which the paresthesia symptom disappeared. No recurrence of the lymphocele has been observed until now, 32 months after the first operation.

As lateral lymph node dissection has come to be more widely performed recently, lymphoceles have occasionally been reported to develop after the surgery. Either surgery or conservative treatment can be selected for symptomatic pelvic lymphoceles. We consider that laparoscopic fenestration is a less-invasive, useful treatment.

A 74-year-old woman presented to our hospital with the complaint of right upper abdominal pain. Abdominal imaging examinations showed marked swelling of the fundus and body of the gallbladder, with wall thickening. The cystic duct was found to be tapering and distorted to the right. The condition was diagnosed as torsion of the gallbladder.

The patient was referred for surgical treatment. Laparoscopy revealed several stringy adhesions between the anterior surface of the liver and the right diaphragm. The floating gallbladder was twisted clockwise around the one of the strings and strangulated. Cholecystectomy was performed. Microscopic examination revealed marked edema of the wall of the fundus and body of the gallbladder. There was no evidence of ischemia or necrosis. A postoperative blood sample was positive for Chlamydia IgA and IgG antibodies. Marked fibrous adhesions between the liver and diaphragm, with a violin string-like funicular substance were noted and considered as components of the Fitz-Hugh-Curtis syndrome. Gallbladder torsion with strangulation is extreme rare, but a delay in the diagnosis and treatment of acute ischemic cholecystitis could become life-threatening; thus, appropriate diagnosis and prompt cholecystectomy are imperative.

Pancreatic pseudocyst is a known complication of chronic pancreatitis. It is generally found in the abdominal cavity and rarely extends to the mediastinum. A 67-year-old man with a history of alcoholism visited a clinic because of epigastralgia. He was diagnosed as having acute chronic pancreatitis and was admitted to hospital. A computed tomography examination revealed an internal pancreatic fistula extending through the esophageal hiatus from the pancreatic pseudocyst in the pancreatic body to cystic lesions in the mediastinum. Endoscopic treatment was deemed to be difficult, and we treated the patient conservatively. However, the conservative treatment was ineffective, and we subsequently performed a planned transgastric internal fistulization of the pancreatic pseudocyst. His postoperative course was uneventful, and he was discharged from hospital. The technique used in the present case might be a useful and important treatment method for pancreatic pseudocyst in cases where endoscopic treatment is thought to be difficult.

A 54-year-old man presenting with right lower abdominal pain was referred to our hospital with suspected appendicitis. A plain CT performed at the previous clinic showed atypical findings for appendicitis. The inflammatory reaction was moderate. Contrast-enhanced CT at our hospital on the day after admission revealed twisting of the omentum with a local mass of fat density. An emergency single-incision laparoscopic omentectomy was performed under the diagnosis of omental torsion, because of persistence of the symptoms with conservative treatment. Laparoscopic examination revealed adhesion of the necrotic omental mass to the right side of the abdominal wall and ileocecum, and we resected the necrotic part of the omentum. The postoperative course was uneventful and the patient was discharged on the fourth postoperative day. Omental torsion is relatively rare and is often misdiagnosed as acute appendicitis. We report the first adult case of idiopathic omental torsion treated by single-incision laparoscopic surgery.

The patient was a woman in her 80s who was admitted with a subcutaneous abdominal mass. Examination revealed overlying skin redness, tenderness, warmth and pus discharge from the mass. Blood examination revealed an increase in the acute inflammatory marker levels. Abdominal CT revealed a highly absorptive foreign body measuring 1.7 cm in size in the region of the abdominal wall redness. A review of a CT performed a year earlier also showed the same foreign body in the abdominal cavity. Based on the findings, we made the diagnosis of abdominal wall abscess due to a foreign body penetrating the abdominal wall. The patient’s general condition was good, so that elective foreign body removal surgery was performed after drainage of the abscess and antibiotic treatment. We confirmed the position of the foreign body preoperatively by abdominal ultrasonography. A part of the foreign body could be visually recognized after clearing some adhesions. The foreign body measured 1.0 cm in length, which was shorter than that observed in the preoperative images, which led to the suspicion that a part of the foreign body remained. We excised the surrounding abdominal wall and omentum, and confirmed the residual foreign body by xeroradiography. We report a rare case of an abdominal wall abscess caused by perforation of a fish bone, in which complete removal of the foreign body was possible, without any residual portion, under the guidance of xeroradiography.

A 72-year-old woman with situs inversus totalis who had undergone hysterectomy presented to us with abdominal distension and anorexia in September 2017. Abdominal computed tomography (CT) revealed an intraperitoneal tumor measuring 52mm in diameter. Positron emission tomography (PET) revealed a maximum standardized uptake value of 3.4 in the tumor. We performed laparoscopically assisted tumor resection, under the differential diagnosis of undifferentiated polymorphic sarcoma, malignant lymphoma, or desmoid tumor. The tumor was located within the jejunal mesentery. Histopathological examination showed spindle-shaped fibroblasts with an abundance of collagen fibers, and the tumor was diagnosed as a desmoid tumor arising from the jejunal mesentery. In 2019 August, a postoperative follow-up CT examination revealed a tumor located in the mesentery, again measuring 52mm in diameter. We suspected recurrence of the desmoid tumor, and performed laparotomy with tumor resection. Histopathology indeed revealed recurrence of the jejunal mesenteric desmoid tumor. While a desmoid tumor in a case of situs inversus totalis is very rare, association of situs inversus totalis with malignant tumors has been reported. Desmoid tumors are also malignant in nature, suggesting that the desmoid tumor in our case was probably a complication of situs inversus totalis. We report a rare case of desmoid tumor with situs inversus totalis.